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Abnormal Psychology, Twelfth Edition
by
Ann M. Kring,
Sheri L. Johnson
Gerald C. Davison,
& John M. Neale
 Chapter
11: Eating Disorders
I. Anorexia Nervosa
II. Bulimia Nervosa
III. Binge Eating Disorder
IV. Etiology of Eating Disorders
V. Treatment of Eating Disorders
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 Eating
disorders are severe disturbances in
eating behaviors, such as eating too little or
eating too much
 Current
DSM-IV Eating Disorder Diagnostic
Categories:
• Anorexia Nervosa
• Bulimia Nervosa
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 Proposed DSM-5 Changes:
• Adding Binge Eating Disorder as a new diagnostic
category, rather than a condition in need of further
study, as it currently is in the DSM-IV
• Eating Disorders likely to become part of “Feeding and
Eating Disorders” group
 Feeding Disorders such as Pica (eating non-food
substances for extended periods) and Rumination
Disorder (repeated regurgitation of foods) are
currently categorized in DSM-IV under Disorders
usually first diagnosed in Infancy, Childhood, or
Adolescence
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 DSM-IV
Diagnostic Criteria:
1. Refusal to maintain normal body weight
 Less than 85%
2. Intense fear of gaining weight and being fat
 Can’t be ‘too thin’
3. Distorted body image or sense of body shape
 Feel “fat” even when emaciated
4. Amenorrhea
 Loss of menstrual period
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 Likely
DSM-5 Criteria:
1. Restriction of behaviors that promote healthy weight;
body weight is significantly below normal
 BMI (Body Mass Index) less than 18.5 for adults
2. Intense fear of gaining weight and being fat
 Can’t be ‘too thin’
3. Distorted body image or sense of body shape
 Feel “fat” even when emaciated
(Amenorrhea not required for diagnosis)
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 Two subtypes
• Restricting
of Anorexia Nervosa:
 weight loss is achieved by severely limiting food
intake, with no binge-eating/purging during the
last three months
• Binge-eating/purging
 the person has also regularly engaged in bingeeating and purging during the last three months
 Longitudinal
research suggests
questionable validity of subtypes
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DSM-5 DIAGNOSES

Anorexia Nervosa
KEY CHANGES FROM DSM-IV




Restriction of behaviors that
promote healthy weight
rather than “refusal to eat”
In addition to fear of weight
gain, a focus on behaviors
that interfere with weight
gain
Loss of menstrual period no
longer required for diagnosis
Subtypes specified for past
three months rather than just
current episode
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 Onset: early to middle teen years
 Usually triggered by dieting and stress
 Women 10x as likely to develop disorder
as men
• Symptomatology in men similar to that of
women
 Often comorbid with depression, OCD, phobias,
panic, alcoholism and PDs
• In men, comorbid with substance dependence,
mood disorders, or schizophrenia
 Suicide rates high in anorexia
• 5% completing
• 20% attempting
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 Low
blood pressure, heart rate decrease
 Kidney and gastrointestinal problems
 Loss of bone mass
 Brittle nails, dry skin, hair loss
 Lanugo
• Soft, downy body hair
 Depletion of potassium and sodium electrolytes
• Can cause tiredness, weakness, and death
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 50-70%
eventually recover
• May often take 6 or 7 years
• Relapse common
 Difficult to modify distorted view of self,
especially in cultures that highly value thinness.
 Anorexia is life threatening
• Death rates 10x higher than general population
• Death rates 2x higher than other psychological
disorders
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 Uncontrollable
eating binges followed by
compensatory behavior to prevent weight
gain
 Likely
DSM-5 Criteria
• Recurrent episodes of binge-eating
 An excessive amount of food consumed in under 2 hours
 A feeling of loss of control over eating
 As if one cannot stop; continues until uncomfortably full
• Recurrent compensatory behaviors to prevent weight gain
 Purging (vomiting), fasting, excessive exercise, use of laxatives
and/or diuretics
• Body shape and weight are extremely important for selfevaluation
• The binge eating and compensatory behaviors both occur, on
average, at least once a week for 3 months
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 Two subtypes:
• Purging (vomiting, laxatives)
• Non-purging (fasting, excessive exercise)
 Validity of two subtypes is questioned
• Research distinguishing the two types is mixed
• Difficulty distinguishing non-purging bulimia from
binge-eating disorder
• Non-purging type is likely to be removed from
DSM-5
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DSM-5 DIAGNOSES

Bulimia Nervosa
KEY CHANGES FROM DSM-IV


Minimum frequency of
binging/purging changed to
once/week instead of
twice/week for at least 3
months
Non-purging subtype
removed
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• Eating Binges
 Triggered by stress or negative emotions or negative
social interactions
 Typical food choices:
 Cakes, cookies, ice cream, other easily consumed, high-calorie
foods
 Avoiding a craved food can later increase likelihood of
binge
 Typically occur in secret
 Reports of losing awareness or dissociation
 Shame and remorse often follow
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 Bulimia
type
vs. Anorexia, binge-eating-purging
• Extreme weight loss in anorexia
• At or above normal weight in bulimia
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 Onset
late adolescence or early adulthood
 90% women
 1 – 2% prevalence among women
 Typically overweight that led to dieting
 Comorbid with depression, PD’s, anxiety,
substance abuse, conduct disorder
 Suicide attempts and completions higher
than in general population but much lower
than in anorexia nervosa
 Bulimics typically have normal BMI
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 Menstrual
irregularities
 Potassium depletion from purging
 Laxative use depletes electrolytes, which
can cause cardiac irregularities
 Loss of dental enamel from stomach acids
in vomit
 Mortality rate of 4%
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 ~75%
recover
 10-20% remain fully symptomatic
 Early intervention linked with improved
outcomes
 Poorer prognosis when depression and
substance abuse are comorbid or more
severe symptomatology
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DSM-IV considers Binge Eating Disorder to be a
diagnosis in need of further study; Binge Eating
Disorder is likely to be included in DSM-5 as a
diagnosis
 Likely DSM-5 Criteria for Binge Eating Disorder:

• Recurrent episodes of binge eating; on average, at least once a week
for three months
• Binge eating episodes include at least three of the following:
 eating more rapidly than normal
 eating until uncomfortably full
 eating large amounts when not hungry
 eating alone due to embarrassment about large food quantity
 feeling disgusted, guilty, or depressed after the binge
• No compensatory behavior is present
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DSM-5 DIAGNOSES

Binge-Eating Disorder
KEY CHANGES FROM DSM-IV


New category in DSM-5
This was in the Appendix in
DSM-IV-TR as a category in
need of further study;
additional research supports
its addition to the DSM-5
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 Binge
Eating Disorder vs. Anorexia:
• Absence of weight loss in Binge Eating Disorder
 Binge
Eating Disorder vs. Bulimia:
• Absence of compensatory behaviors (purging,
fasting, or excessive exercise) in Binge Eating
Disorder
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 Associated
with obesity and history of dieting
• Body mass index (BMI) > 30
 Not
all obese people meet criteria for binge eating
disorder
• Must report binge eating episodes and a feeling of loss of
control over eating to qualify
• Approximately 2-25% of obese may qualify
 Risk factors include:
• Childhood obesity, early childhood weight loss attempts,
having been taunted about their weight, low self-concept,
depression, and childhood physical or sexual abuse
 Equally
prevalent among Euro-, African-, Asian-,
and Hispanic-Americans
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 Problems associated with obesity:
• Increased risk of Type II diabetes
• Cardiovascular disease
• Breathing problems
• Physical ailments (joint/muscle pain)
 Problems independent of obesity:
• Sleep problems
• Anxiety/Depression
• Irritable Bowl Syndrome
• Early menstruation in women
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 About
60% (between 25 and 82%) recover
 Binge Eating Disorder is the most common
and lasts the longest of the three Eating
Disorders
• Lasts on average: 14.4 years
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 Family
and twin studies support genetic link
• First-degree relatives of individuals with both disorders
more likely to have the disorder
• Higher MZ concordance rates for both anorexia and
bulimia
 Body
dissatisfaction, desire for thinness, binge
eating, and weight preoccupation all heritable
 Environmental factors (e.g., family interactions)
play an even greater role in etiology
• Further research on genetic/environmental interaction is
needed
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 Hypothalamus
not directly involved
 Low levels of endogenous opioids
• Substances that reduce pain, enhance mood, and
suppress appetite
• Released during starvation
 May reinforce restricted eating of anorexia
• Excessive exercise increases opioids
• Low levels of opioids (beta-endorphins) in bulimia
promote craving
 Reinforce binging
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 Serotonin
related to feelings of satiety
(feeling full)
• Low levels of serotonin metabolites in anorexics
and bulimics
• Antidepressants that increase serotonin often
effective in treatment of eating disorders
 Dopamine
related to feelings of pleasure
and motivation
• Anorexics feel more positive and rewarded when
viewing pictures of underweight women
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 Anorexia
• Focus on body dissatisfaction and fear of fatness
• Certain behaviors (e.g., restrictive eating, excessive
exercise) negatively reinforcing
 Reduce anxiety about weight gain
• Feelings of self control brought about by weight loss are
positively reinforcing
• Perfectionism and personal inadequacy lead to
excessive concern about weight
• Criticism from family and peers regarding weight can
also play a role
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 Bulimia
• Self-worth strongly influenced by weight
 Low self-esteem
• Rigid restrictive eating triggers lapses, which can
become binges
 Many “off-limit” foods
• After binging, disgust with oneself and fear of gaining
weight lead to compensatory behavior
 e.g., vomiting, laxative use
• Purging temporarily reduces anxiety about weight gain
 Negative feelings about purging lead to lowered self-esteem,
which triggers further bingeing
• Stress, negative affect trigger binges
• Restrained eating plays central role in bulimia
 Restraint Scale measures dieting and overeating
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 American
society values thinness in
women, muscularity in men
 Dieting, especially among women, has
become more prevalent
• Often precedes onset
 Body
dissatisfaction and preoccupation
with thinness also predict eating
disorders
 Societal objectification of women
• Women viewed as sexual objects
 Unrealistic
media portrayals
• Women may feel shame when they don’t match
the ideal
 Overweight
individuals are viewed with
disdain, creating more pressure to be thin
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 Objectification of women’s bodies
• Women defined by their bodies; men defined by
their accomplishments
• Societal objectification of women leads to “selfobjectification”
 Women see their own bodies through the eyes of others
 Leads to more shame when fall short of cultural ideals
 Aging
and changes in life roles (having a
life partner, or having children) associated
with decreased eating-disorder symptoms
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 Anorexia
found in many cultures
• Even those not under Western influence
• May not include fears of getting fat
 In
some cultures, higher weight is a sign of
fertility and healthiness
 As countries become more like Western
cultures, eating disorders increase
 Bulimia more common in industrialized
societies than non-industrialized ones
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 White women compared to women of color
• Gap in rate of eating disorders between white women and
women of color is diminishing, particularly with bulimia
 Greatest gap in college women
• More dieting and body dissatisfaction in white teens
 BMI increases linked to greater body dissatisfaction
 Body
dissatisfaction and symptoms of bulimia
strongly correlated with high acculturation
stress
 Prevalence
of binge eating disorder and bulimia
in Latina women comparable to Caucasian;
anorexia is more rare
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
Eating behaviors impact personality
• Semi-starvation leads to preoccupation with food
and personality changes

Personality characteristics impact eating
• Perfectionism, lack of interoceptive awareness,
and negative affect predicted disordered eating
 Perfectionism remains high even after treatment

Family characteristics
• Self report indicates high levels of family conflict
 Parental reports don’t always indicate family problems
• One observational study showed parents had no
greater levels of negative statement than controls
• More observational studies needed
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 Self
reports of high rates of childhood
sexual and physical abuse
 Reports of abuse not specific to eating
disorders
• Also found in other diagnostic categories
 Presence
of abuse may be too general
variable
• Age and type of abuse may be more significant
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 Antidepressants
• Effective for bulimia but not anorexia
• Dropout and relapse rates high
• Limited research suggests that antidepressant
medications are not effective in reducing binges or
increasing weight loss in binge-eating disorder
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
Anorexia
• Immediate goal is to increase weight to avoid medical
complications and avoid death
• Second goal is long-term maintenance of weight gain
 Can be even more challenging

CBT
• Reductions in symptoms through 1 year

Family-based therapy (FBT) found to be effective
• Anorexia viewed as an interpersonal, rather than individual
issue
• Use of “Family Lunch” sessions
• Early results show improved outcomes over individual
therapy
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 Bulimia
• Challenge societal ideals of thinness
• Challenge beliefs about weight and dieting
• Challenge all-or-nothing beliefs about food
 One bite of high-calorie food does not have to lead to bingeing
• Increase self-assertiveness skills to improve
interpersonal relatedness
• Increase regular eating patterns (three meals a day)
• CBT more effective than medication
 Adding Exposure and Ritual Prevention (ERP) increases
effectiveness of CBT in the short term
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 Binge-Eating
Disorder
• CBT shown to be effective treatment modality
 Teaches restrained eating through self-monitoring, selfcontrol, and problem solving skills
• CBT more effective than medication
• Interpersonal Therapy (IPT) equally as effective as
CBT
• Behavioral weight-loss programs may promote
weight loss, but do not curb binge eating
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 Psychoeducational approaches
• Educate early about the dangers of eating disorders
 De-emphasize sociocultural influences
• Dissonance reduction intervention to deemphasize
sociocultural influences
 Risk-Factor Approach
• Healthy weight intervention to develop healthy
weight and exercise programs
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Copyright 2012 by John Wiley & Sons, Inc. All
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